PATIENT INFORMATION Name: Address: (Last) (First) (Middle) (Street) (City) (State) (Zip) Home Phone: Cell Phone: Email Address: Birth Date: Age: When is the best time to contact you? May we email you for additional information? Please tell us the best way to contact you: Home Email Cell Who referred you for genetic counseling? What is the reason you have been referred for genetic counseling? Have you or any family member had genetic testing before? Office Use ID: Other family members in HCRP (Hereditary Cancer Risk Program): Genetic Counseling Location: Dallas Plano All Saints Page 1 of 6
Ethnic Background? Race? Please check all that apply Adopted Hispanic/Latino Your Background All Participants t Hispanic/Latino American Indian/Eskimo/Aleut Asian or Pacific Islander Black White Other includes all other responses not listed above. Patients who consider themselves as multiracial or mixed should choose this category. What country is your mother s family from? What country is your father s family from? What is the highest Elementary School Middle School High School level of education you completed? Some College College Degree Graduate / Professional Degree What is your occupation? Your current height: Your current weight: Colon Cancer Screening Your Health History All Participants Have you every had a colonoscopy? Yes, when: What were the results? Have you ever been told you have unusual skin findings (ex: lumps, bumps, lesions, light or dark spots)? Dermatological Yes, what: Have you had any exposures that could affect cancer risks? (ex: radiation, chemical plants, work exposures, smoking) Do you have any Briefly describe any health problems here: ongoing health problems? Yes Page 2 of 6
Your Health History Female Participants Only Menstrual History Pregnancy History (if applicable) Have you ever taken birth control pills? When did you begin your menstrual cycles? Years old Have you gone through menopause? Yes, age: times have you been pregnant? children have you had? How old were you when you had your first child? If yes, for how long? years Have you ever taken hormone replacement therapy? Have you had your uterus removed? If yes, how many years? At what age did you start? If yes, reason: If yes, at what age? Type Have you had your ovaries removed? Have you ever had a breast biopsy? Result of last breast biopsy If yes: One Ovary Both Ovaries If yes, reason: If yes, at what age? If yes, how many have you had? # If yes, at what age(s)? Invasive (lobular or ductal carcinoma) In-situ DCIS (ductal carcinoma in situ) or LCIS (lobular carcinoma in situ) Atypical hyperplasia (AH) Other: Unknown Page 3 of 6
Biopsy Type: Other Biopsy History All Patients Result: Biopsy Type: Result: Breast Cancer History (if applicable) All Patients Cancer in which Breast? Right Left Age at diagnosis: Lumpectomy left right Mastectomy left right Surgeon: Radiation Therapy Radiation Oncologist: Chemotherapy Other Treatment: Oncologist: Other Personal Cancer History (if applicable) All Patients What type of cancer were you diagnosed with? What treatment did you have? Age at diagnosis: Physician(s): Page 4 of 6
Family History Please list all of your family members that have been affected by any type of cancer Name (First name only okay) M (male) or F (female) Relationship please be specific Examples: Aunt Mom s side, Great Aunt Dad s father s sister, Cousin Mom s sister Judy s daughter Age Now or Age at Death (N or D) (ex: 55 N) Location of Cancer (ex: breast, thyroid, colon, etc) Age of Cancer Diagnosis (Estimate if not known) Had anyone in your family tested positive for a mutation in a cancer gene? If yes, what gene? (if yes, please bring a copy of your family member s test result to your appointment) Page 5 of 6
Your Family Tree Mother Age: Father Age: (now or age deceased) (now or age deceased) N = Age Now D = Deceased Total (Indicate half siblings and side Dad / Mom) Ages N = Age Now D = Deceased Total (Indicate half siblings and side Dad / Mom) Ages sisters do you have? brothers do you have? daughters do you have? sons maternal aunts (Mom s side) maternal uncles (Mom s side) paternal aunts (Dad s side) paternal uncles (Dad s side) Do you have any questions or concerns for the genetic counselor? Please fax or email this questionnaire before your appointment Fax: 214-820-9606 Email: cancergenetics@baylorhealth.edu Thank you! Page 6 of 6